An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain.

The patient is anxious, fearful, and hyperventilating.

What acid-base imbalance does the nurse anticipate the patient will develop?

Respiratory alkalosis.

Respiratory acidosis.

Metabolic alkalosis.

Metabolic acidosis.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Hyperventilation leads to a decrease in the amount of carbon dioxide (CO2) in the blood. This causes the pH of the blood to increase, resulting in respiratory alkalosis.
Choice B rationale
Respiratory acidosis is caused by a buildup of CO2 in the blood, typically due to hypoventilation (under-breathing). This is not consistent with the patient’s symptoms of hyperventilation.
Choice C rationale
Metabolic alkalosis is typically caused by a significant loss of acid from the body, such as from prolonged vomiting. This is not consistent with the patient’s symptoms.

Choice D rationale
Metabolic acidosis is typically caused by an increase in acid production within the body or a loss of bicarbonate from the body, such as in diabetic ketoacidosis or kidney disease. This is not consistent with the patient’s symptoms.

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Correct Answer is C

Explanation

Choice A rationale

Monitoring capillary refill distal to the infusion site is a general nursing intervention during IV therapy. However, it is not specific to the administration of a vesicant chemotherapeutic agent.

Choice B rationale
Applying a topical anesthetic at the infusion site for burning is not a standard intervention during the administration of a vesicant chemotherapeutic agent. The burning sensation is not due to the IV site but due to the vesicant agent itself.

Choice C rationale
Assessing the IV site frequently for signs of extravasation is the most appropriate intervention during the administration of a vesicant chemotherapeutic agent. Extravasation, the leakage of the vesicant into the surrounding tissue, can cause severe local tissue damage. Early detection and intervention are crucial to minimize harm.

Choice D rationale
While it is important to explain potential side effects to the client, explaining that temporary burning at the IV site may occur is not the most crucial intervention. The priority is to monitor for and prevent extravasation.

A. You made a promise to your mother that you need to keep B. Moving your mother into a care facility will show her that you do not love her C. Helping your mother should be easier than raising a child D. Involve your mother in the decision-making process E. It is okay not to love or like your mother when you are caring for her F. Take time for yourself and the other relationships that you care about G. Saying “no” to things involving the care of your mother is a selfish action

Correct Answer is ["D","E","F"]

Explanation

Choice D rationale
Involving the mother in the decision-making process can help alleviate some of the stress associated with caregiving. It allows the mother to maintain some control over her care and ensures that her needs and preferences are being met.
Choice E rationale
It is normal to have mixed feelings when caring for a loved one. Acknowledging these feelings can be an important part of managing caregiver stress.
Choice F rationale
Taking time for oneself and maintaining other relationships is crucial for caregiver well-being. It can help prevent burnout and improve the quality of care provided to the mother.

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An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain. The patient is anxious, fearful, and hyperventilating. What acid-base imbalance does the nurse anticipate the patient will develop?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

Correct Answer is C

Explanation

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care. Select the 3 statements that the nurse should include when discussing caregiver stress with the client’s daughter.

Correct Answer is ["D","E","F"]

Explanation

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An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain.

The patient is anxious, fearful, and hyperventilating.

What acid-base imbalance does the nurse anticipate the patient will develop?